Clinical corticosteroid use

Question 1

What conditions are corticosteroids used for to provide anti-inflammatory/ immunosuppressive therapy?

Answer 1

Asthma, COPD, eczema, rhinitis
Hypersensitivity conditions
Graft prevention/ transplant rejection
Rheumatoid arthritis, inflammatory bowel disease
Autoimmune diseases e.g. lupus
Pre-term labour
Temporal arteritis

Question 2

How are corticosteroids used as adjunct treatment in cancer?

Answer 2

Combined with cytotoxic drugs for Hodgkin’s disease, acute lymphocytic leukaemia
Reduce cerebral oedema associated with brain tumours
Combined with anti-emetic drugs in conjunction with chemotherapy

Question 3

In what condition are glucocorticoids used as replacement therapy?

Answer 3

Addison’s

Question 4

What are the causes of adrenal hyperfunction?

Answer 4

More common in females
Over-production of ACTH
ACTH-independent adrenal cortical tumour
Rare ectopic CRH-secreting tumour
All produce hypercortisolism, Cushing's disease or Cushing's syndrome

Question 5

What are the causes of Cushing’s disease and Cushing’s syndrome?

Answer 5

Cushing’s disease- Associated with excess pituitary ACTH secretion
Cushing’s syndrome- other tumours and also seen after prolonged glucocorticoid therapy

Question 6

What are the characteristics of Cushing’s syndrome?

Answer 6

High plasma and urine cortisol (and high plasma ACTH if due to pituitary/ectopic ACTH-secreting tumour)
Low/undetectable plasma ACTH if due to adrenal tumour

Question 7

What are the diagnostic tests for Cushing’s syndrome?

Answer 7

Measure cortisol in blood, urine and saliva- levels will be especially high at night
Overnight dexamethasone suppression test- inhibits cortisol production for 24 hours normally
Metyrapone- inhibits cortisol production normally

Question 8

What are the symptoms of Cushing’s syndrome?

Answer 8

Moon face with red cheeks
Buffalo hump around neck
Increased abdominal fat
Thin arms and legs due to muscle wasting
Bruise easily, poor wound healing
Obesity
Increased appetite and infection susceptibility

Question 9

What is the treatment of Cushing’s syndrome?

Answer 9

Surgical removal of pituitary, ectopic or adrenal tumour and life long corticosteroid replacement
Gradual discontinuation of synthetic glucocorticoids
Metyrapone- in ectopic ACTH secreting tumours not amenable to surgeryand for controlling symptoms prior to surgery, many side effects
Ketoconazole- inhibits several enzymes, prevents fungi steroid synthesis
Pasireotide- surgery failed or inappropriate, switches off ACTH

Question 10

What are the characteristics of immunosuppression?

Answer 10

Opportunistic infections- get coughs and colds at a more severe level
Reduced response to infection

Question 11

What is the advice for people who are immunosuppressed?

Answer 11

Avoid live vaccines- should have dead-attenuated vaccines
Avoid exposure to infectious diseases, in particular:
chickenpox/shingles- passive immunisation with varicella-zoster immunoglobulin
measles- can use normal immunoglobulinfor prophylaxis
Treat infections aggressively

Question 12

What are the possible psychiatric reactions to corticosteroid therapy?

Answer 12

Euphoria
Nightmares
Mood swings
Paranoia
Suicidal thoughts
Psychotic reactions
Behavioural changes
Depression

Question 13

How should psychiatric reactions to corticosteroids be treated?

Answer 13

Need to reduce dose/ discontinue steroid
Advise patients to seek medical advice if symptoms of depression and suicidal thoughts
Take care in people predisposed to psychiatric reactions, and/or have family history

Question 14

What are the characteristics of adrenal suppression?

Answer 14

Can take up to one year for body to start making steroids
Down regulated CRH and ACTH due to exogenous sterooid
Recover quickly in first two weeks of treatment and steroid production continues
> 3 weeks treatment: adrenal cortex shrinks and endogenous steroid production stops
If stop therapy suddenly after > 3 weeks treatment, at risk of Addisonian crisis
Aldosterone production is unaffected by long term steroids

Question 15

What are the symptoms of Addisonian crisis?

Answer 15

Severe hypertension, severe circulatory collapse with feeble rapid pulse and soft heart sounds
Very weak and confused
Pyrexia common and may be due to underlying infection
Loss of appetite, nausea and vomiting, severe abdominal pain occurs very frequently
Can have increased motor activity progressing to delirium/ seizures
Death due to circulatory collapse and arrhythmias with hypoglycaemia contributing (treat with steroids e.g. IV hydrocortisone

Question 16

How to minimise side effects from corticosteroid use

Answer 16

Lowest effective dose for shortest time possible
Give dose in morning
Alternate day regimens- double dose treatments every other day, doesn’t work in asthma
Intermittent therapy with short courses where possible
Use steroid sparing agent e.g. azathioprine to reduce the dose of steroid
Use local routes of administration where possible

Question 17

How to manage illness in patients on steroids

Answer 17

During infection may need to increase steroid dose
Surgery- extra dose of hydrocortisone as pre-med, extra dose of hydrocortisone in following 2-3 days
Vomiting- may need IV dose, maintain calcium levels, steroids can cause huge drop in BP

Question 18

Gradual withdrawal of corticosteroids

Answer 18

Not necessary if course < 3 weeks

Gradual reduction after longer courses- prevents flare ups and withdrawal symptoms

Question 19

Gradual withdrawal of systemic corticosteroids should be considered in those whose disease is unlikely to relapse and have:

Answer 19

> 40mg prednisolone daily or for > 7 days
Had repeated evening doses
3 weeks treatment
Taken a short course within one year of stopping long term therapy
Recently received repeated courses (particularly if >3 weeks)
Other causes of adrenal suppression

Question 20

If stress e.g. infection, trauma, surgery occurs up to one week after stopping corticosteroid:

Answer 20

Additional corticosteroid cover is needed to compensate for any potential adrenal suppression

Question 21

Patient information

Answer 21

Explain side effects
Steroid card- for > 3 weeks treatment, covers precautions to minimise risk of adverse effects, details of prescriber, drug, dosage and duration of treatment
Stress compliance
Missing doses
Starting/stopping courses
Infection and other illnesses